Quadrigeminal Cistern Research Articles

Quadrigeminal cistern arachnoid cyst causing hydrocephalus.

The quadrigeminal cistern is an unusual location for these cysts. Quadrigeminal arachnoid cysts account for 5% to 10% of all intracranial arachnoid cysts. They are frequently diagnosed coincidentally on computed tomography (CT) or magnetic resonance imaging (MRI). They cause symptoms when they become sufficiently large to compress the adjacent brain structures. Endoscopic fenestration of the cyst with cystocisternostomy or cystoventriculostomy, when combined with third ventriculostomy, is the procedure of choice for such patients. A 14-month-old boywas referred to neurosurgery clinic due to increased head circumference. His had been in good health until age 8 months, between age 9 and 13 months his acquisition of developmental skills was slow. Magnetic resonance image (MRI) demonstarted enlargement of the supratentorial ventricular system secondary to a large quadri-geminal cistern arachnoid cyst compressing the brainstem, cerebellum, aqueduct of Sylvius and fourth ventricle. The cystic mass appeared hyperintense on T2 weighted-images (A, B), hypointense on T1-WI (C, D), similar to cerebrospinal fluid (CSF) signal, without enhancement after Gadolinium administration. The patient was operated by transventricular approach with endoscopic third ventriculocystostomy and endoscopic third ventriculostomy (ETV). The postoperative course was uneventful.

Supracerebellar Infratentorial Endoscopy for Quadrigeminal Cistern Epidermoid

The standard microscopic supracerebellar infratentorial approach for the pineal region is limited by tunnel vision. Herein, we describe endoscopic supracerebellar infratentorial surgery in a patient with quadrigeminal cistern epidermoid presenting with hydrocephalus. In the sitting position, following a 6 cm longitudinal incision and small suboccipital craniotomy, the dura was cut in V shape and kept reflected. The bridging veins were coagulated and cut, taking the 0° endoscope inside. A sharp incision is given over the thickened arachnoid over the inferior paramedian area. The precentral cerebellar vein is exposed at the lower part, coagulated and divided. Gentle bimanual intracapsular removal of the epidermoid flakes is performed with intermittent saline irrigation and suction. Assisted by rotating the angled endoscope, curved coaxial instruments help remove the cerebello-mesencephalic and lateral extensions of the epidermoid. Endoscopic supracerebellar infratentorial approach provides a panoramic and angled view of the pineal region, through a narrow corridor, avoiding cerebellar retraction.

Discussion on the surgical methods of radiation-induced encephalopathy mainly featured with cystic change in the temporal lobe

Objective To assess the clinical outcomes of various surgical methods of radiation-induced encephalopathy (REP) mainly featured with cystic change in the temporal lobe. Methods A retrospective study was conducted on the clinical data of 56 patients with REP mainly featured with cystic change in the temporal lobe who underwent surgery at Department of Neurosurgrey, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University from January 2010 to December 2016. Among them, 24 peoples underwent merely lesionectomy (control group), while the other 32 peoples underwent lesionectomy and cistern opening (experimental group). According to the postoperative outcome, KPS (Karnofsky performance status) score, the volume of lesion on MRI and clinical follow-up , we compared the surgical effect between the 2 groups. Results In control group, 7 patients (29.2%) reported relief of chief complaint, while 23 patients (71.9%) in experimental group had relief. The difference was statistically significant (P<0.05). The KPS score was 70.13±19.10 in control group and 84.16±13.47 in experimental group, which had significant difference (P<0.05). The volume of lesion post surgery was (32.35±20.85)cm3 in group and (13.31±6.44)cm3 in experimental group, which had statistical difference (P<0.05). The follow-up data showed that the readmission rate in experimental group (18.7%, 6/32) was lower than that in control group (75.0%, 18/24). which had significant difference(P<0.05). Conclusion For REP mainly featured with temporal lobe cyst, the surgical operation should include further dissection of cisterna ambiens and cisterna interpeduncularis in addition to merely lesionectomy, which could help prevent the formation of isolated cyst cavity with space-occupying effect and achieve better therapeutic results. Key words: Temporal lobe; Radiation encephalopathy; Neurosurgical procedures; Treatment outcome

Lesión como malformación de Chiari secundaria a quiste aracnoidal de la cisterna cuadrigémina

Se presenta el caso de una mujer de 31 años de edad con cefalea y cervicalgia que se agravaba con la maniobra de Valsalva, presentando además mareos, encontrándose una malformación de Chiari secundario a un quiste aracnoideo cuadrigeminal. Después de efectuada la resonancia magnética diagnóstica, la paciente fue sometida a descompresión del agujero magno y extirpación del quiste cuadrigeminal, seguido por la resolución tanto de la malformación de Chiari y el quiste. Los síntomas desaparecieron después de la cirugía y han permanecido completamente resuelto hasta la actualidad. En pacientes adultos que presentan signos y síntomas de una malformación de Chiari debido a la compresión de la médula por las las amígdalas cerebelosas, la presencia de un quiste aracnoideo de cisterna cuadrigéminal es una rara patología asociada que puede ser tratada quirúrgicamente.

Supracerebellar Infratentorial Approach for Complex Thalamic Cavernous Malformation: 2-Dimensional Operative Video.

Key points for the approach include the use of a supracerebellar infratentorial craniotomy, dynamic and gravity retraction, lighted bipolar forceps and suction, and stereotactic navigation. This patient has a large cavernous malformation extending from the midbrain to the thalamus in craniocaudal extent. The cavernous malformation extends to the midbrain surface along the interface with the ambient cistern, making it appropriate for the supracerebellar infratentorial approach. By cutting the tentorium access to the superior extension becomes feasible. The cavernous malformation is excised in a piecemeal manner utilizing a CO2 laser. Because removal of the large mass allowed the partial collapse of the cavity, a small segment of the cavernous malformation obscured by the collapse is retained cranially along the foramen of Monro. This situation required a return to the operating room for complete excision. The patient tolerated both procedures well and remained at her neurological baseline postoperatively. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. The surgical video has been used with permission from the Barrow Neurological Institute.

Low-dose cisplatin combined with etoposide in the treatment of low-grade glioma in the sellar region of children with diencephalic syndrome: A report of four cases

Objective To investigate the therapeutic effect of low-dose cisplatin combined with etoposide on low-grade glioma in the sellar region of children with diencephalic syndrome. Methods The clinical characteristics, treatment and outcomes of 4 children with diencephalic syndrome secondary to low-grade glioma in the sellar region were retrospectively analyzed who were admitted to Department of Neurosurgery, Children's Hospital of Fudan University from January 2015 to December 2017. Of 4 cases, 2 were females and 2 were males. The range of age was 6 months to 34 months, with the median age of 16 months. One case with severe hydrocephalus was treated with ventriculoperitoneal shunt surgery. Surgical biopsy or resection was not performed in this series. Low doses of cisplatin (1 mg·kg-1·d-1 d0-d2) and etoposide (5 mg·kg-1·d-1, d0-d2) were used for 10 cycles of chemotherapy to observe the clinical effect. Results All cases successfully completed chemotherapy and no obvious side effects of chemotherapy were reported. Follow-up post chemotherapy lasted for 6 to 20 months (with the median duration of 12 months). The clinical symptoms were better than before and the weight was about 29.3%-50.0% higher than before. The starting time to gain weight was 3 to 12 months after the initiation of chemotherapy (with the median duration of 7 months). There was no progress in the review of cranial MRI saddle area in 2 cases, tumor reduction in 1, substance decrease in 1, disappearance of cisterna ambiens lesion in 1 and disappearance of the fourth ventricular lesion in 1. There was no significant change in hormone level compared with conditions prior to chemotherapy. One case gained weight at 1 year post chemotherapy and presented good clinical performance. Partial resection of tumor was performed. Its final pathological result was pilocytic astrocytoma (WHO Ⅰ) and further radiotherapy was administered. Conclusions The chemotherapy regimen of low-dose cisplatin combined with etoposide seems to have a good effect which was to improve the clinical symptoms and postpone the tumor progression of children with diencephalic syndrome secondary to low-grade gliomas in the sellar region. Key words: Glioma; Child; Cisplatin; Etoposide; Diencephalic syndrome; Sellar region; Low-grade

The Tactics of Surgical Treatment in Patients with Cerebellar Infarction

The aim of the study is to specify tactics of surgical treatment of cerebellar infarction (CI). Material and methods . The results of treatment of 80 patients with CI were studied. According to the clinical course of stroke, the patients were divided into 2 groups. The group of malicious cerebellar infarction included 55 patients (69%) (Group I), the group cerebellar infarction with benign course included 25 patients (31%) (Group II). Patients of Group I were divided into subgroups, in one of them surgical treatment was performed (surgical subgroup), and in the another one, only conservative (conservative subgroup) treatment was performed. In the surgical subgroup, 16 patients underwent isolated ventriculostomy, 5 - posterior fossa decompression (PFD), 18 - combination of ventriculostomy and PFD. The criteria of efficacy of surgery were recovery of consciousness and/or IV ventricle and the quadrigeminal cistern configurations. Results of treatment were assessed according to the Glasgow Outcome Scale. Results. Malicious cerebellar infarctions occurred more frequently in patients with volume of ischemia exceeding 20 cm 3 in the first day of the disease. The threshold value of mass effect, which may cause further a malocious cerebellar infarction, in the first day of the disease was score 3 according to the M. Jauss scale. In group of patients with malicious cerebellar infarction, surgical treatment reduced the mortality rate of occlusion and dislocation syndrome by 35.8%. The most effective type of intervention was a combination of decompressive trepanation of the posterior cranial fossa and external ventricular drainage. Combined ventriculostomy and PFD were 34 % more effective than just ventriculostomy, and 38 % more effective than just PFD. Conclusion. Patients with cerebellar infarction of more than 20 cm3 and signs of a mass effect in the posterior cranial fossa score 3 or higher according to M. Jauss scale, are prone to developing a malicious course of the disease. After the development of clinical manifestations of occlusive and dislocation syndrome, they need surgical treatment. In the surgical treatment of malignant cerebellar infarction, ventriculostomy with PFD are advisable, as each operation separately does not always provide a necessary effect in decompensation of dislocation syndrome.

Hydatid cyst of the quadrigeminal cistern

Intracranial hydatid cyst involves supratentorial area and mainly affecting the middle cerebral artery territory with the predilection of the partial lobe. It can be single - which is the most common - or multiple up to 35 cysts. They tend to be huge at the time of symptomatic presentation especially when they are presented as a solitary lesion with a slow growth rate around 1.5 cm/year, however, it is variable and it can be up to 10 cm/year. Surgical treatment is mandatory for all patients once the correct diagnosis is made, except for patients with multiple organ involvement in poor general conditions and deep-located cysts. The existence of hydatidosis in the cisternal spaces must not be neglected given the capacity of E. granulosus larvae to disseminate via the CSF. In this case report; two and half years’ male child presented with a history of 2 attacks of generalized seizure for the last 72 hours with the head circumference at the upper normal limit for his age. This paper presents the first case report demonstrating a primary single hydatid cyst located in the quadrigeminal cistern in a child. We concluded that in spite of the feasibility of the imaging and the high suspension of cerebral hydatid cyst, still, the reports show more locations which can be described as unusual although for a head to toe suspected distribution of hydatid disease is already understood. An eminent medical and surgical (if indicated) treatment of the primary cerebral hydatid cyst are always effective and recommended.

The Subtemporal Approach to the Lateral Midbrain with and without Zygomatic Osteotomy: An Anatomical Study.

The subtemporal approach provides a narrow operative corridor to the crus cerebrum and adjacent structures of the crural, interpeduncular, and ambient cistern. Addition of a zygomatic osteotomy widens this narrow corridor and spares retraction of the temporal lobe. We investigate and compare the morphometric parameters of the subtemporal approach with versus without zygomatic osteotomy. On each side of four cadaveric heads, a temporal craniotomy was performed to gain access to the crus cerebrum and adjacent subarachnoid cisterns using a subtemporal approach. Operative corridor width and corridor working angle were measured with and without brain retraction on each specimen side. Next, a zygomatic osteotomy was performed followed by full downward reflection of the temporalis muscle and further drilling of the squamous part of the temporal bone. Lastly, operative corridor width and corridor working angle were measured again for comparison. The subtemporal operating corridor was (mean/SD): 5.8/2.6 mm without retraction, 11.4/4.3 mm with retraction, and 13.5/6.5° working angle. After addition of a zygomatic osteotomy, the operative corridor was 8/9.2/4.3 mm without retraction, 14.7/4.5 mm with retraction, 31.8/3.1° working angle. Zygomatic osteotomy significantly increased the operative corridor working angle of the subtemporal approach. Furthermore, we demonstrate a direct approach into the interpeduncular fossa. Clin. Anat. 32:710-714, 2019. © 2019 Wiley Periodicals, Inc.

The clinical and radiological features of cisternal and pericallosal lipomas.

To demonstrate the clinical and radiological features of pericallosal and cisternal lipomas and to compare these two groups in terms of radiological and clinical features. This retrospective study included 23 patients diagnosed with pericallosal and cisternal lipoma between 2010 and 2017. The patients comprised 12 females and 11 males with a mean age of 38.8years (range 12-69years). Magnetic resonance imaging was applied to all the patients. Computed tomography (CT) was also performed in 10 patients. 9 lesions were pericallosal and 14 were cisternal (7 were right quadrigeminal cistern, 3 were left quadrigeminal cistern, 1 was interpeduncular cistern, 1 was left cerebellopontine cistern, 1 was right cerebellopontine cistern, and 1 was supracerebellar cistern). The mean size of the lesions was 18.7 ± 10mm. The shape of the lesions was curvilinear in 10 patients (43.5%) and tubulonodular in 13 patients (56.5%). The mean CT density of the lesions was - 87.7 ± 25.6HU. The size of pericallosal lipomas (mean 27.5mm) was statistically significantly larger than that of cisternal lipomas (mean 13.1mm) (p = 0.001). No statistically significant difference was determined between the two groups in terms of lesion shape (p = 0.478), gender (p = 0.707), age (p = 0.639), and symptoms (p = 0.084). In this study, the incidence of pericallosal lipomas was 0.011% and the incidence of cisternal lipomas was 0.017%. Although rare, the knowledge of the clinical and radiological features of pericallosal and cisternal lipomas will play an important role in the accurate diagnosis and follow-up of the patient.

Posterior Approach to Meckel's Cave: Retrosigmoid Craniectomy with Endoscopic Assistance.

Background Meckel's cave involvement in tumors pose a challenge due to their surrounding neurovascular structure and deep location. Case Review A 24-year-old male presented with progressive headaches and right sided trigeminal neuralgia with a large epidermoid. The tumor extended from the ambient cistern to the cerebellomedullary cistern and involved Meckel's cave ( Fig. 1 ). Technical Note/Video Description A retrosigmoid craniectomy was performed. Cranial nerves 3, 4, 6, 7, and 10, and auditory brainstem responses were monitored. Once the craniectomy was completed the dura was opened and cerebrospinal fluid (CSF) was released from the cisterna magna to allow for the tumor resection to be done without the use of any retractors ( Fig. 2 ). Care was taken to ensure that cranial nerves in the posterior fossa were detethered to prevent any traction injury. Using ring curettes the pearly white epidermoid tumor was able to be debulked. After all the possible tumor was resected with the microscope, the 30-degree endoscope was used to identify the porus trigeminus. Malleable ring curettes and a malleable suction were used to remove the soft tumor from this location. The patient transiently had loss of hearing but this returned within 2 weeks after surgery. Conclusions The retrosigmoid approach is familiar to all neurosurgeons and with the adjunct of an angled endoscope, the posterior Meckel's cave can be easily reached. This is particularly useful for tumors with soft consistency. The assistance of the endoscope allows Meckel's cave visualization without additional drilling while still allowing safe resection of tumor from around the trigeminal nerve. The link to the video can be found at: https://youtu.be/01aqOyUmSW0 .

Fully Endoscopic Supracerebellar Infratentorial Approach for Resection of Third Ventricle Germ Cell Tumor: 2-Dimensional Operative Video.

Pineal tumor that extends into the posterior portion of the third ventricle is extremely deep-seated and surgically challenging. Various microscopic approaches have been introduced to acquire access to the posterior third ventricle, but still the exposure and visualization are relatively unfavorable. However, recently the application of high-definition endoscope gave neurosurgeons a much more magnified and clearer view of anatomy around the pineal region and third ventricle. The widely used supracerebellar infratentorial approach has been proven to offer a sufficient surgical corridor for fully endoscopic surgery for pineal tumor. We presented a case of a 13-yr-old male child with a posterior third ventricle tumor, which was surgically resected fully with the endoscope. An informed consent has been obtained from the patient and his guardians. In order to gain enough auto-retraction by gravity, diminish the pitfalls of the semisitting position, and enhance the surgeon's ergonomics, the patient was positioned with a modified "head-up" park bench position (the upper body was elevated and the head was slightly extended instead of anteflexion). The tumor was approached through suboccipital midline supracerebellar infratentorial trajectory. The superficial and deep drainage veins above the vermis were sacrificed and the quadrigeminal cistern was entered to expose the tumor. The first and the most important step of the operation was to de-vascularize the tumor bilaterally, then the tumor could be debulked and circumferentially resected. The gross total resection was achieved. Fully endoscopic supracerebellar infratentorial approach is feasible and efficient when addressing lesions located at the posterior portion of the third ventricle.

Endoscopic transorbital transtentorial approach to middle incisural space: preclinical cadaveric study.

Endoscopic transorbital approach is a novel development of minimally invasive skull base surgery. Recently, anatomical studies have started to discuss the expanded utilization of endoscopic transorbital route for intracranial intradural lesions. The goal of this cadaveric study is to assess the feasibility of endoscopic transorbital transtentorial approach for exposure of middle incisural space. Anatomical dissections were performed in four human cadaveric heads (8 sides) using 0- and 30-degree endoscopes. A stepwise description of endoscopic transorbital transtentorial approach to middle incisural space and related anatomy was provided. Orbital manipulation following superior eyelid crease incision with lateral canthotomy and cantholysis established space for bone drilling. Extradural stage consisted of extensive drilling of orbital roof of frontal bone, lessor, and greater wings of sphenoid bone. Intradural stage was composed of dissection of sphenoidal compartment of Sylvian fissure, lateral mobilization of mesial temporal lobe, and penetration of tentorium. A cross-shaped incision of tentorium provided direct visualization of crural cistern with anterolateral aspect of cerebral peduncle and upper pons. Interpeduncular cistern, prepontine cistern, and anterior portions of ambient and cerebellopontine cisterns were exposed by 30-degree endoscope. The endoscopic transorbital transtentorial approach can be used as a minimally invasive surgery for exposure of middle incisural space. Extensive drilling of sphenoid wing and lateral mobilization of mesial temporal lobe are the main determinants of successful dissection. Further studies are needed to confirm the clinical feasibility of this novel approach.

Multimodal assessment using early brain CT and blood pH improve prediction of neurologic outcomes after pediatric cardiac arrest

BackgroundEarly prediction of neurologic prognosis in children resuscitated from cardiac arrest is a major challenge. This study aimed to investigate the usefulness of a combined model based on brain computed tomography (CT) and initial blood gas analysis to predict neurologic prognoses in pediatric patients after cardiac arrest. MethodsWe retrospectively analyzed the medical records of patients resuscitated after cardiac arrest from 2000 to 2018. Patients aged one month to 18 years were included. Gray to white matter ratio (GWR), ambient cistern effacement (ACE), and blood gas analysis were studied. The primary outcome was neurological prognosis, which was evaluated using the Pediatric Cerebral Performance Category (PCPC) scale at discharge. ResultsOf 97 resuscitated patients, 64 brain CT images were available. Fourteen patients had a good neurologic outcome (PCPC 1–3) and 50 patients a poor neurologic outcome (PCPC 4–6). The multimodal model (AUC 0.897) containing GWR of basal ganglia (BG), ACE, and blood pH was found to be superior for predicting poor neurologic prognosis than single variable models (AUC of GWR-BG: 0.744, ACE: 0.804, pH: 0.747). Interestingly, we found the GWR-BG cutoff value for specificity 100% differed significantly between patients <4 years (cutoff value: 1.08, p = 0.04) and ≥4 years (cutoff value: 1.18, p = 0.004). ConclusionsThe combination of GWR-BG, ambient cistern effacement, and blood pH was found to usefully predict neurological outcome in children resuscitated from cardiac arrest. In addition, the cutoff value of GWR-BG for the prediction of neurologic outcome was found to increase with age.

Preoperative Predictors and Prognosticators After Microsurgical Clipping of Poor-Grade Subarachnoid Hemorrhage: A Retrospective Study

Contrary to expectations, some patients with poor-grade subarachnoid hemorrhage (SAH) show favorable outcomes. However, the factors predictive of good prognosis are unclear. The purposes of this study were to identify factors related to poor-grade SAH and to analyze preoperative prognostic factors. We included 186 patients with SAH who underwent surgical clipping or conservative treatment immediately after SAH diagnosis. Physiologic, radiographic, and blood examination data were collected retrospectively. Factors related to poor World Federation of Neurological Societies (WFNS) grade (WFNS IV and V) and poor outcome (modified Rankin Scale scores 3-6) were analyzed. The patients (mean age, 61.6 years) included 134 women (72%). Seventy patients (38.2%) had poor WFNS scores. On multivariate analysis, age ≥70 years (adjusted odds ratio [OR], 3.73), midline shift (OR, 4.89), and the absence of cerebrospinal fluid in the high-convexity cortical sulci (OR, 5.47) and ambient cistern (OR, 4.83) were predictive of poor WFNS scores. Age ≥70 years (OR, 8.36), WFNS grade 5 (OR, 15.35), intracerebral hematoma (OR, 3.32), and Evans index (EI) ≥0.3 (OR, 4.40) were predictive of poor outcome. Body mass index (OR, 0.87), intraventricular hemorrhage (OR, 3.86), glycated hemoglobin level (OR, 2.78), and age ≥70 years (OR, 4.12) were predictive of EI ≥0.3. Poor outcomes correlated with older age, brain-destructive hemorrhage, and EI ≥0.3. The EI reflects both hydrocephalus and the patient's frailty. Radiographic signs of poor-grade SAH were not correlated with poor outcome, suggesting that early decompressive surgery may improve outcome.

Surgical treatment of malignant cerebellar infarction

The study objective is to evaluate the effectiveness of various methods of surgical treatment of malignant cerebellar infarction.Materials and methods. There were 47 patients with malignant cerebellar infarction retrospectively analyzed in this study. The group 1 included all patients who underwent surgical treatment (n = 31), the group 2 included all patients who underwent conservative treatment (n = 16). In the group 1, 15 patients underwent isolated ventriculostomy, 4 – posterior fossa decompression (PFD), 14 – combination of ventriculostomy and PFD. The criteria of efficacy of surgery were: restoration of consciousness, restoration of forth ventricle and the quadrigeminal cistern configurations. Results of treatment were assessed according to the Glasgow outcome scale.Results. The recovery of consciousness level was observed in 7 out of 15 patients after isolated ventriculostomy on average 13 day; the efficacy was 47 %. Four patients underwent only PFD. Among them 2 patients needed additional external ventricular drainage installation as 2nd operation. The efficacy was 50 %. After PFD with simultaneous ventriculostomy the recovery of consciousness was observed on 4 day in 11 out of patients. The efficacy was 79 %. Combined ventriculostomy and PFD were 32 % more effective than ventriculostomy alone, and 29 % more effective than PFD alone.Conclusion. In patients with malignant cerebellar infarction with a decrease in consciousness and signs of brainstem compression, ventriculostomy with PFD are advisable, because isolated ventriculostomy does not always provide a necessary effect in decompensation of dislocation syndrome.

Unedited microneurosurgery of a pineal region neuroepithelial cyst.

Background:Neuroepithelial cysts are benign, well-circumscribed, nonenhancing CSF-like masses that might virtually present in any intracranial location. Common locations are the frontal lobe, thalamus, midbrain and pons, vermis, the lateral and fourth ventricles, and the choroid fissure (Choroid fissure cysts). Usually asymptomatic, cysts in the posterior fossa have been reported to cause cranial nerve palsies, focal brainstem dysfunction, and hydrocephalus. Supratentorial cysts might cause seizures or focal motor and/or sensory deficits. Histopathological examination reveals that neuroepithelial cysts are lined by ependymal (columnar epithelium) or choroid plexus cells (low cuboidal epithelium). The differential diagnosis includes enlarged perivascular spaces, infectious cyst-neurocysticercosis, porencephalic cyst, and arachnoid cyst.Case Description:A patient with a symptomatic histologically confirmed pineal region neuroepithelial cyst underwent park bench position and a right supracerebellar infratentorial approach. The pineal region was accessed over the right cerebellar hemisphere and the lesion was identified after a lateral opening of the quadrigeminal cistern. After a careful dissection of the lesion, the cyst was pulled out with long ring microforceps and long sharp bipolar forceps; both assisted by a thumb-regulated suction tube. A complete lesion was removed in a piece and meticulous attention was paid to any bleeding securing complete hemostasis of the surgical site. The postoperative course was uneventful. The patient underwent rehabilitation without recurrence of the lesion.Conclusion:This unedited video offers all detailed aspects that a neurosurgeon as the senior author JH considers essential when performing an efficient and safe surgery into the pineal region for this very rarely documented pineal region neuroepithelial cyst.Videolink:http://surgicalneurologyint.com/videogallery/pineal-cyst-4

Malignant cerebellar infarction: clinical course and surgical treatment

To clarify the indications for surgical treatment of malignant cerebellar infarction (CI). Eighty patients with CI were studied. The malignancy of CI was understood as the development of mass effect in the posterior cranial fossa, accompanied by the decrease in consciousness due to compression of the brain stem and/or the development of occlusive hydrocephalus. The patients were divided into 2 groups. The group of malignant CI included 55 patients (68.75%) (group I), the group of benign CI included 25 patients (31.25%) (group II). Patients of group I were divided into subgroups, one of them underwent surgical treatment (surgical subgroup), and another only conservative (conservative subgroup) treatment. Surgery efficacy criteria were: restoration of consciousness to 15 points according to GCS and/or restoration of the fourth ventricle and the quadrigeminal cistern configurations. Results of treatment were assessed according to the Glasgow outcome scale. Malignant CI occurred more frequently in patients with the volume of ischemia exceeding 20 cm3 (p<0.05) in the first day of the disease. The threshold value of mass effect, which can cause further a malignant CI, was 3 points according to the M. Jauss scale. In the group of patients with malignant CI, surgical treatment reduced the mortality rate from occlusion and dislocation syndrome by 35.8%. The most effective type of intervention was a combination of decompressive trepanation of the posterior cranial fossa and external ventricular drainage. In patients with CI with the volume more than 20 cm3 and signs of mass effect in the posterior cranial fossa on the scale of M. Jauss 3 points or more, the malignant course of the disease develops in 67% of cases. These patients require careful monitoring, and, in case of development of malignant CI, surgical treatment is necessary.

Unedited microneurosurgery of a pineal region ependymoma.

Background:Ependymomas are rarely located in the pineal region. The 2016 WHO classification of tumors of the central nervous system includes five ependymal tumors, the grade I subependymoma and mixopapillary ependymoma, the grade II ependymoma, the grade II–III ependymoma RELA fusion-positive, and the grade III anaplastic ependymoma. However, this grading system has been controversial with respect to its reproducibility and clinical significance and it is estimated that further studies of the molecular characteristics of ependymoma will provide more precise and objective classification. Herein, we present an unedited microneurosurgery of a gross total removed WHO grade II ependymoma.Case Description:A patient with a histologically confirmed WHO grade II ependymoma underwent a sitting praying position and a supracerebellar infratentorial paramedian approach. Under high magnification, the pineal region was accessed over the right cerebellar hemisphere. A tight dorsal membrane of the quadrigeminal cistern was opened laterally with microscissors. Tissue samples were obtained with ring microforceps for histological study. Internal debulking of the tumor was performed with the combination of the suction tube and bipolar forceps aiming to open the posterior wall of the third ventricle. Concentric retraction of the tumor with ring forceps was associated with medial and inferior dissection of its cleavage plane with the thumb-regulated suction tube. Similarly, the lateral border of the lesion was dissected with a combination of the suction tube and bipolar forceps. Once, the tumor was detached from the surrounding tissue, soft but continuous traction with ring forceps was required to pull out this lesion in a single piece. Small remnants were removed as well and the apparent origin zone of the tumor was detached with bipolar forceps. Meticulous attention was paid for the hemostasis and few minutes were considered to observe any bleeding site. Finally, some pieces of surgicel covered small bleeding dots. The postoperative course was uneventful with only slight double vision that improved gradually. The patient did not receive radiochemotherapy and is alive and free of recurrence >10 years after surgery.Conclusion:This unedited video offers all detailed aspects that a neurosurgeon as the senior author JH considers essential when performing an efficient and safe surgery into the pineal region for this very rarely documented pineal region ependymoma.Videolink: http://surgicalneurologyint.com/videogallery/pineal-tumor-4/

Unedited microneurosurgery of a mixed germ cell tumor of the pineal region.

Background:Germ cell tumors comprise a heterogeneous group of neoplasms, classified as germinomas and nongerminomatous germ cell tumors based on clinicopathological features. The nongerminomatous group of tumors includes embryonal carcinoma, endodermal sinus tumor (yolk sac tumor), choriocarcinoma, mature and immature teratoma, and mixed germ cell tumors with more than one element. While germinomas are radiation-sensitive tumors, all other tumors have less response to radiotherapy, and it is suggested that gross total resection improves their overall survival and tumor-free survival rates. Herein, we present the microsurgical management of a histologically confirmed mixed-germ cell of the pineal region.Case Description:A patient with a mixed germ cell tumor underwent sitting praying position and midline supracerebellar infratentorial approach. After opening of the dura, a midline cerebellar vein was coagulated and cut, and the pineal region was accessed over the superior cerebellar surface. A tight reactive dorsal membrane of the quadrigeminal cistern was widely opened with subsequent evaluation of the neurovascular structures by intraoperative angiography. Under high microsurgical magnification between both basal veins, the dorsal wall of the fibrotic and solid tumor was coagulated and opened aiming an internal debulking of the lesion. Water dissection and cotton dissection were useful tools to separate the lateral borders of the tumor from the surroundings. Bipolar coagulation was helpful shrinking the tumor as well. The superior borders of the lesion, firmly attached to the roof of the third ventricle, required a careful evaluation. Ring microforceps in the right hand and thumb-regulated suction tube in the left one allowed us to pull out the tumor in a piece under soft and continuous traction with dissection of the cleavage plane. The superior attachment of the tumor was coagulated and cut. Finally, bipolar coagulation and small pieces of surgicel ensured a proper hemostasis. Postoperatively, the patient had a partial gaze palsy that improved gradually. The patient underwent adjuvant radiochemotherapy and currently is alive, free of tumor recurrence >12 years after surgery.Conclusion:This unedited video offers all detailed aspects that a neurosurgeon as the senior author JH considers essential when performing an efficient and safe surgery for a mixed germ cell tumor.Videolink: http://surgicalneurologyint.com/videogallery/pineal-tumor-5